Can someone help me with this nursing home visit scenario as this provider tends to document all his nursing home visits in this format. Documentation reads: 60 day visit. Stable, no acute changes. Non-verbal today. HEENT negative. Neck: supple. Lungs: clear. Heart: regular R&R. Abdomen: soft, non-tender. Extremities: no edema, Neuro: no interval changes. Total care reviewed. No changes.

There are no diagnoses on the progress note but the superbill states: Alzhemeiers without behavioral disturbances, and diabetes.

I feel this is not acceptable, that the documentation does not support the diagnosis stated on the superbill. Shouldn't the diagnosis be documented on the progress note and do you think that diabetes should be mentioned in the body of the progress note. I would like to approach the provider regarding this but would like some advice.